Moderate Sedation Certification SOLUTIONS GRADE A+ GUARANTEED

Moderate "Conscious" Sedation A minimally depressed level of consciousness induced by the administration of pharmacologic agents in which the patient retains continuous and independent ability to maintain protective reflexes and a patent airway and to be aroused by physical or verbal stimulation. Levels of Sedation Analgesia 1. Minimal Sedation 2. Moderate Sedation/Analgesia 3. Deep Sedation/Analgesia 4. General Anesthesia Minimal Sedation 1. Patient is able to respond normally to verbal stimulation. 2. Airway and Spontaneous Ventilation is not affected and thus "normal" 3. Cardiovascular function is not affected Moderate Sedation/Analgesia 1. Patient responds to verbal or tactile stimulation 2. No intervention to maintain patent airway 3. Spontaneous ventilation is adequate 4. Cardiovascular function is usually maintained Deep Sedation/Analgesia 1. Patient responds to repeated or painful stimulation 2. May require intervention to maintain patent airway 3. Spontaneous ventilation may be inadequate 4. Cardiovascular function is usually maintained General Anesthesia 1. Patient cannot be aroused, even with painful stimuli 2. Intervention required to maintain patent airway 3. Spontaneous ventilation is frequently inadequate 4. Cardiovascular function may be impaired Goals of Safe Sedation 1. Maintain adequate ventilation, homeostasis, and circulation 2. Maintenance of appropriate level of consciousness 3. Promote comfort by elevating pain threshold 4. Patient Safety-be knowledgeable about possible consequences of respiratory depression, airway obstruction, apnea, hypoxia, hypercapnia, bradycardia, asystole, brain injury/death 5. Using the essential components required to conduct safe sedation 6. Understand the importance of a systematic approach to sedation that promotes safety and efficacy. Role of the Sedation Nurse 1. Pre-op Nursing Assessment 2. Intra-op Nursing Actions: medication administration; patient monitoring; patient safety; procedure specific 3. Post-op monitoring during recovery 4. Follow post-op d/c criteria 5. Explain post-d/c written instructions 6. Follow-up JCAHO Care Standard: Qualified Individuals conducting sedation must possess education, training, and experience in? 1. Evaluating patients prior to moderate or deep sedation 2. Rescuing patients who slip into a "deeper than desired" level of sedation or anesthesia 3. Managing a compromised airway during a procedure 4. Handling a compromised CV system during a procedure. Pre-Operative Nursing Assessment Steps 1. Chart Review 2. Patient Interview 3. Physical Exam and Review of Systems Pre-sedation Assessment Overview: Parts of the Assessment 1. NPO Status 2. Chief complaint 3. Current medications 4. Drug allergies 5. H/O substance abuse 6. Concurrent medical problems 7. Communication Ability How is Aspiration Risk Reduced 1. Pre-procedure fasting--Defined as no food for 6 hours prior to procedure. May have clear fluids until 2h prior to procedure. 2. Medication is titrated to maintain reflexes What conditions place patient's at enhanced risks for aspiration with sedation? 1. Obesity 2. DM 3. Pregnancy 4. Bowel Dysfunction Patient history to consider during pre-op preparation 1. Smoking- PPD and years 2. Drug allergies and reaction 3. Alcohol Abuse 4. Menstrual Hx and Urine HCG for fertile women 5. Height and Weight to dose medications 6. Drug Abuse 7. Daily Medications 8. Post Facial/Neck Trauma or Surgery 9. Dentures or any removable items in mouth Elements of Pre-operative Preparation 1. Patient counseling 2. Rapport 3. Verbal reassurance 4. Patient expectations 5. IV Access 6. EKG/BP 7. Pulse Ox 8. Informed Consent Pre-Sedation Assessment: Chart Review 1. Past medical illnesses 2. Prior Surgical Procedures 3. Allergies 4. Drug reactions and intra-anesthetic complications 5. Lab Studies 6. Current medications 7. Compliance of medication regimen Pre-Sedation Assessment: Ancillary Studies 1. Recent EKG (1year) 2. Patients at risk for myocardial injury (anti-hypertensive) 3. Pregnant, must have OB consult 4. 5 years old require a consult with anesthesia ASA Physical Status American Society of Anesthesiologists Physical Status System helps qualify the relative risk to patients sedative medications pose ASA 1 -Normal, healthy adult -No chronic illness -No regular medications -Excludes very young and very old -Good exercise tolerance ASA 2 Mild systemic disease: -Controlled HTN -Type II DM -H/O tobacco use -Obesity -Non-metastatic carcinoma -Well controlled asthma -Child with underlying cerebral palsy -Child with well-controlled seizure disorder ASA 3 *Severe systemic disease that is not incapacitating: -Poorly controlled HTN -Multiple medications for cardiac, respiratory, and/or metabolic disorders -Metastatic dz with some interference with function -PNA *Divided into Stable and Unstable ASA 4 *Severe systemic dz that is a constant threat to life -COPD on multiple inhalers and difficulty breathing supine -Metastatic dz with severe organ dysfunction -Recent MI with continuing symptoms -Severe HTN with angina -Sepsis -Organ insufficiency ASA 5 *Moribund patient not expected to survive longer than 24 hours without surgical intervention ASA 6 *Declared brain-dead whose organs are being removed for donor purposes Physical Examination: Cardiac Considerations 1. H/O myocardial infarction -Assess for angina -Assess for SOB: at rest; w/ exercise/activity; paroxysmal nocturnal dyspnea -Signs of CHF -Elective procedures postponed at least 6 months post-MI 2. Will the patient be able to lie flat for procedure? -Paroxysmal nocturnal dyspnea 3. Subacute Bacterial Endocarditis Prophylaxis before and after procedure necessary -Valvular heart disease 4. HTN-Controlled? Compliance? 5. Recent Cardiac Sx 6. Dysrhythmias 7. Pacemaker or Automatic Internal Defibrillator? Cardiovascular Physical Assessment should include 1. Skin color 2. Peripheral pulses 3. Presence of edema or jugular vein distention 4. Baseline heart rate 5. BP 6. Auscultation of heart soudns Pulmonary System Physical Assessment 1. Does the patient have a current cough, sputum production, rhinitis, sore throat, dyspnea, hemoptysis, wheezing? 2. Use oxygen at home? 4. Physical characteristics that may indicate potential difficult airway management Physical characteristics that can indicate potential for difficult airway management -Obesity -Short, thick neck -Limited neck ROM -Deviated trachea -Hypognathic (recessed) jaw -Hypergnathic (Protruding) jaw -Small mouth opening (3cm) -High arched palate -Macroglossia (Large tongue) -Protruding teeth -Loose teeth or dentures -Non visible uvula -Tonsillar hypertrophy Extra precautions necessary with asthmatic patients 1. Pre-op bronchodilator 2. Steroid-dependent asthmatics are NOT candidates for nursing administration of sedatives 3. Presence of wheezing despite bronchodilators and steroid therapy should be consulted by anesthesia Extra precaution for chronic bronchitis patients Pre-op inhaler bronchodilator Instructions for conscious sedation given for a short term procedure (1h) administered to patients with DM that are well controlled on oral hypoglycemics 1. Do not take scheduled AM dose of oral hypoglycemic 2. Fasting blood glucose morning of procedure 3. Post-op finger stick Insulin dependent patients require anesthesia consultation Danger for DM under deep sedation CONTINUED.....